International Journal of Hospital Research 2018, 7(3): x-x doi 10.15171/ijhr.2018.

xx
http://ijhr.iums.ac.ir
Research Article

Improving the Quality of Hospital Services

Using the QFD Approach and Integration
With Kano Analysis Under Budget
Constraint
Mohammad Ali Beheshtinia1*, Ali Mardani1, Masood Kord1

Industrial engineering department, Semnan university, Semnan, Iran

1

Abstract
Background and Objectives: One of the main concerns of hospital managers is their ability in improving their
organization’s performance. The use of quality management and decision-making techniques facilitates managers
to achieve this goal. In this research, the corrective activities to increase the quality of hospital services are
determined and selected using an integration of the quality function deployment (QFD) method with the kano
analysis and Knapsack Problem Mathematical Model (KPMM). This approach is implemented in a private hospital
in Iran.
Methods: First, the customers’ wants are identified. The corrective activities are then identified to meet these
wants, and the relationship between each corrective activity and each want is determined. Next, the types of
the wants are identified based on the kano analysis, and their weights are determined using their degree of
importance and type. Then, the final weight of each corrective activities is obtained based on the wants’ weights
and the relationship matrix. Finally, KPMM is used to select the optimum list of corrective activities under budget
constraint.
Findings: This study identifies 30 customers’ wants among them “Professional and experienced doctors and
nurses” and “ Healthy and sufficient consumables” obtained the highest weights. Results show that there are 2
“Attractive” customer wants, 15 “One-dimensional” customer wants and 13 “Must-be” customers’ wants. Finally,
30 corrective activities were identified which are placed at house of quality. The corrective activities “Training of
physicians and nurses” and “Increasing staff sense of responsibility” obtained the highest weights.
Conclusions: Utilizing the kano analysis for determining the weight of customers’ wants in the house of quality
approach causes the organization’s strategies taken in to account in prioritizing corrective activities. Moreover,
KPMM leads to an optimum selection of corrective activities.
Keywords: Hospital, House of quality, Kano analysis, Functional expansion

Background and objectives results in customer satisfaction.14

Healthcare is a crucial issue in every society, which
has become increasingly important in recent years as
living standards have changed and the need for better
healthcare to improve the lifestyle is felt. In recent years,
1
a variety of research studies have been constructed
in the field of healthcare performance evaluation,2-7
optimization 8-10
and quality enhancement. 11,12
Hospitals
not only should provide health care services but also
address the issues of increasing customer satisfaction.
Improving hospital services based on customers’ wants
*Corresponding Author: Mohammad Ali Beheshtinia, Industrial en-
gineering department, Semnan University, Semnan, Iran, Tel/Fax:
+982333654275, Email: beheshtinia@semnan.ac.ir
There are various customer-oriented tools for managers
to evaluate services and improve their services, such as
quality function deployment (QFD),12 Kano’s model,11
multi-criteria decision making,15-17 etc. In this study,
QFD is used to identify and prioritize the implementation
of corrective activities to meet the customers’ wants.
Moreover, the kano analysis is used to identify the types
of customers’ wants and determine their weight. For better
13
understanding, the proposed approach is applied to a
private hospital in Iran. In this research, in addition to the
patients’ requests, the needs of the patients’ companions
have also been considered. Therefore, in the rest of the
paper, the word customer is used to consider both patient
and companions of the patients.

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 2 Beheshtinia etal
This study integrates the QFD approach with the Kano
analysis and Knapsack Problem Mathematical Model
(KPMM) to improve the quality of hospital services under
budget constraint.
Kano developed a model for classifying product or
service features based on how they are able to meet the
customer’s needs. 18
These wants are divided into 5 sections:
1) The must-be wants: these are the requirements that
the customers expect and are taken for granted. When
done well, customers will only be neutral, but when done
poorly, customers will be very dissatisfied.
2) One-dimensional wants: these attributes result in
satisfaction when fulfilled, and dissatisfaction when not
fulfilled.
3) Attractive wants: these attributes provide satisfaction
when fully achieved, but do not cause dissatisfaction
when not fulfilled.
4) Indifferent wants: these attributes refer to aspects
that are neither good nor bad, and they result in neither
satisfaction nor dissatisfaction.
5) Reverse wants: These attributes refer to a high
degree of achievement resulting in dissatisfaction and
to the fact that not all customers are alike.
shows how customers’ wants in the kano analysis are
segmented.
Some researchers have used Kano analysis to improve
service quality. Materla et al 11
developed Kano analysis
to identify a wide range of complex patient needs
or convey its potential usefulness in the continuous
improvement of the healthcare sector. Wang and Fong
presented a fuzzy Kano analysis to identify customers’
perceptions and increase their satisfaction from the
airline services. Behdioğlu et al 20
evaluated services
quality in a physiotherapy and rehabilitation hospital in
Turkey. Using the Kano analysis, Zobnina and Rozhkov
provided a model for customer satisfaction with existing
Figure 1. Kano Model.
Int J Hosp Res 2018, Volume 7, Issue 3
Improving the Quality of Hospital Services Using the QFD
hotels in Europe. Ali et al22 Presented an approach to
identify and compare the level of patients’ expectations
of healthcare and their perceived using the SERVQUAL
method. Farokhnia and Beheshtinia23 developed a three-
dimensional house of quality model to enhance the service
quality in an airline and an airport in Iran. Cetinkaya et al24
presented a university curriculum with the help of QFD.
Wood et al25 developed a method for identifying factors
(customers’ concerns) which affect the quality of the green
hospital.
The QFD is a comprehensive quality system that aims to
translate customers’ wants into corrective activities.26 The
main part of QFD is the house of quality (HOQ) matrix,
which consists of two main components: WHATs and
HOWs. WHATs are data that identify the customers’ wants
and HOWs are data that provide solutions for them, named
corrective activities. When using QFD, the essential factor
is to define and understand WHATs (customers’ wants)
and HOWs (corrective activities).
Figure 2 shows an HOQ, in which the numbered parts
are: (1) the identified customers’ wants; (2) the identified
corrective activities to meet the customers’ wants; (3)
calculations related to the weights of the customers’
19
Figure 1 wants; (4) the relationship between the customers’ wants
and the corrective activities, and (5) the prioritization of the
corrective activities.
Some researchers integrated QFD with other techniques
to obtain more accurate results. Fauziah et al27 carried
out a research on integrating QFD and SERVQUAL for
using in a hospital pharmacy. Raziei et al28 developed an
12
integrated model by QFD, SERVQUAL and group decision
making to improve the service quality in hospitals. Wibawa
et al29 Introduced an approach by integrating SERVQUAL
and Kano with QFD to improve the hospital information
system in a private hospital. Gao and Zhang30 introduced
21
hidden costs of quality resulting from patient dissatisfaction
and used the QFD and SERVQUAL methods to calculate
these costs. Camgöz-Akdağ et al31 improved service
quality in the healthcare industry by integrating QFD
Figure 2. House of Quality.
Improving the Quality of Hospital Services Using the QFD Beheshtinia etal
3

with SERVQUAL analysis. Osorio-Gómez and Manotas-
Duque presented a multi-criteria model using fuzzy QFD
32
and TOPSIS for maritime transportation.
On the other hand, the knapsack problem is a problem
in combinatorial optimization: Given a set of items, each
with a weight and a value, determine the number of each
item to include in a collection so that the total weight is
less than or equal to a given limit and the total value is as
large as possible.
Some studies have investigated the integration of QFD
and the Kano analysis simultaneously. Garibay et al33
presented a combination of the Kano analysis and QFD
as a useful tool for evaluating the quality of digital library
service at a Mexican university. Kuo et al examined the 34
integration of the Kano analysis and the QFD method to
improve hotel services. Vaziri and Beheshtinia integrated
QFD, SERVQUAL and the kano analysis in the field of
life insurance services. Baki et al developed a model to
36
improve logistics services quality using the QFD approach
and its integration with SERVQUAL and the kano analysis.
Beheshtinia and Farzaneh Azad37 provided a model to
improve the quality of hotel services by integrating QFD
with the Kano analysis and the SERVQUAL analysis.
Moreover, some researches use combination of QFD
and kano analysis in healthcare systems and hospital
services.29,38-44
As seen in the literature, applying some techniques
such as MCDM, SWOT, QFD, etc in various case studies
may lead to new findings and it could be said that there is
a contribution in applying the same technique in various
organizations in the mentioned scopes. For example,
implementing QFD in various organizations may lead to
new customers’ wants or new technical requirements.
Table 1 depicts the previous papers categorized based
on the tools used in the studies and their case studies.
Review of previous studies in the literature shows that no
35
study in the literature integrates QFD, kano analysis and
KPMM in the hospital services.
The research contributions are as follows:
• Integration of QFD, Kano analysis and KPMM in
the hospital services
• Applying the proposed approach in a hospital in

Table 1. The Categorization of Previous Studies

Researcher Case Study Kano QFD Hospital Services KPMM

Cetinkaya et al (2019) Educational services 

Fauziah et al (2019) Pharmaceutical services 

Materla et al (2019) Hospital services  

Osorio-Gómez and Manotas-Duque (2019) Supply chain and logistics 

Farokhnia and Beheshtinia (2018) Airline and Airport services 

Raziei et al (2018) Hospital services  

Zobnina and Rozhkov (2018) Hotel and tourism 

Beheshtinia and Farzaneh Azad (2017) Hotel and tourism  

Vaziri and Beheshtinia (2016) Insurance services  

Wang and Fong (2016) Airline services 

Kuo et al (2016) Hotel and tourism  

Wood et al (2016) Green hospital design 

Gao and Zhang (2016) Healthcare services  

Wibawa et al (2016) Hospital Information system  

Yeh and Chen (2014) Healthcare services  

Camgöz-Akdağ et al (2013) Hospital services  

Gupta and Srivastava (2011) Healthcare services  

Nordin and Che Razak (2010) Healthcare services  

Garibay et al (2010) Digital library services  

Yeh (2010) Hospital services   

Baki et al (2009) Logistics services  

Chiou and Cheng (2008) Healthcare services  

Mustafa (2002) Hospital services   

Our study Hospital services    

Int J Hosp Res 2018, Volume 7, Issue 3

 4 Beheshtinia etal Improving the Quality of Hospital Services Using the QFD

Tehran, Iran and identifying a new Research Steps

Methods
Research Questions
In this study, the main research question is as follow:
What is the optimum set of corrective activities to enhance
quality of hospital services under budget constraint?
Research sub-questions are as follows:
What are the hospital customers’ wants?
What is the type of customers’ wants based on the kano
analysis?
What are the importance degrees of customers’ wants?
What are the weights of customers’ wants?
What are the corrective activities required to satisfy the
identified customers’ wants?
What is the relationship between the corrective activities
and the customers’ wants?
How much is the estimated cost of implementing each
identified corrective activity?
Data Gathering
Four types of questionnaires are used in this study. The first
questionnaire is based on the Kano analysis to determine
the type of the customers’ wants. The questionnaire
consists of two positive and negative questions about
considering or ignoring each want in the services provided
by the hospital.
The second questionnaire identifies the customers’
wants’ importance degree. The respondents of both
questionnaires used a 5-point Likert scale (Table 2) to
answer the questions. As shown in Table 2, scores 1 to
5 (from least significant to most significant) are assigned
to the importance degree of requirements from the clients’
point of view. Finally, according to the scores collected
from clients, the mean of importance scores is calculated
for each need.
The third questionnaire is used to determine the
relationship between the customers’ wants and corrective
This study presents a QFD approach and integrates it
with the kano analysis and KPMM to improve the quality
of hospital services under budget constraint. The research
steps are described below. Figure 3 shows an overview of
the research steps.
Step 1: Identify the customers’ wants
These wants are identified by the experts’ opinions, the
literature review, and interviews with the customers
Step 2 Identify the corrective activities required to satisfy
the customers’ wants
Step 3: Determine the relationship matrix
Each corrective activity is related to at least one of the
customer wants. The HOQ relationship matrix is used to
illustrate and simplify these relationships. The customers’
wants and corrective activities are placed in the rows and
columns of the HOQ matrix, respectively. The arrays in
this matrix are the values of the relationship matrix in
accordance with Table 2.
Step 4: Identify the importance of customers’ wants
The second questionnaire helps to identify the
importance degree of the customers’ wants. The greater
the importance degree of a want, the more attention
managers should pay to that want.
Step 5: Calculate the type of the wants based on the
Kano analysis
In this step, the customers’ wants are divided into
five categories of must-be, one-dimensional, attractive,
indifferent, and reverse wants using the second
questionnaire.
Step 6: Calculate the weight of the customers’ wants
To calculate the final weight of each customer’s
want, the values of its importance degree is multiplied
by its type. The related values to the type of wants are
Table 2. Linguistic Variables of the First and Second Questionnaires and
the Related Scores
Importance Degree Questionnaires Relate Score

activities, in which the respondents’ options are presented Very Low 1

in Table 3.Table 3 shows the type and numerical value of Low 2

the relationship between needs and corrective activities. Medium 3

The fourth questionnaire is used to identify the cost of High 4

implementing each corrective activity by experts. Very High 5

According to Cochran’s formula, assuming a 5% error,

385 questionnaires are distributed in the hospital in
Table 3. Symbols and Scores for the Relationship Matrix
each case over a five-month period. The third and fourth
Type of Relationship Notation Relate Score
questionnaires are completed by eight experts. Because
Strong ● 9
the used questionnaires are standard, their validity have
Moderate ○ 5
been confirmed.35 The reliability of the questionnaire was
Weak ∆ 1
confirmed by Cronbach alpha test.
No relationship Blank 0

Int J Hosp Res 2018, Volume 7, Issue 3

Improving the Quality of Hospital Services Using the QFD Beheshtinia etal
5

Figure 3. Overview of the research steps

determined according to the organization’s strategies. If

j, dij is the value of the relationship between want i and
the organization’s strategy is to retain current customers,
corrective activity j, and REWj is the relative weight of
a higher value should be allocated to the basic wants.
corrective activity j. A higher value for the weight of a
However, if the organization’s strategy is to attract new
corrective activity indicates its higher importance and
customers, a higher value should be assigned to the
higher priority for being implemented by the managers.
attractive wants.
Step 8: Estimate the cost of implementing each
corrective activity
AWi= ki ×II (1) Step 9: Employ KPMM to select optimum list of corrective
n activities
RWi = AWi / ∑AWi (2)
To select the optimum list of corrective activities, the
i =1
KPMM is employed as follows:
In this formula, Ki is the value related to the type of want
m
i according to the kano analysis and Ii is the importance
degree of want i. Finally, AWi and RWi are the absolute
Max Z
= ∑REWj × X
j=1
j

and relative weights of want i.

m
Step 7: Calculate the corrective activities’ weights and
their priority
St: ∑C × X
j=1
j j ≤ B (5)
The corrective activities do not have the same
X i ∈ {0,1} i=
1, 2, …, n .
importance. Some corrective activities require more
attention than others. The corrective activities’ weights are
Where B is the total budget and Xj is the decision
calculated using the following equation:
variable in which it is 1 if corrective activity j in selected
n and vice versa. REWj and Cj are the weight of jth activity
AEWj
= ∑dij × AWi
i =1
(3)
and its estimated cost, respectively.
m
REWj = AEWj / ∑AEWj (4)
Results
j =1
To illustrate the performance of the proposed approach,
where AEWj is the absolute weight of corrective activity
it was applied to a private hospital located in Tehran,

Int J Hosp Res 2018, Volume 7, Issue 3

 6 Beheshtinia etal
Iran. The results of implementing the research steps are
presented in this section.
Identifying the Customers’ Wants
In the first step, the customers’ wants are identified. In
addition to the medical wants, the mental condition and
other customer related services are considered. Finally,
30 wants were identified, as shown in Figure 4.
Identifying the Corrective Activities
The hospital performance can be improved systematically
by implementing corrective activities considering the
priority given. At this stage, 30 corrective activities were
identified to satisfy the customers’ wants, as shown in
Figure 4.
Determining the Relationship Matrix
In this step, using the third questionnaire, the relationship
of each corrective activity, and each customer want is
determined according to Figure 4.
Identifying the Importance of the Customers’ Wants
The importance degrees of the wants obtained by the
second questionnaire are shown in Table 4. As determined
in Table 4, the clients’ wants of R24, R14 and R26 are of the
highest importance degree.
FIgure 4. House of Quality.
Int J Hosp Res 2018, Volume 7, Issue 3
Improving the Quality of Hospital Services Using the QFD
Determine the Type of The Wants Based on the Kano
Analysis
The results of this step are shown in Table 4. The “Must-be,”
“one-dimensional,” and “attractive” wants are represented
by the symbols M, O, A, respectively. The weight assigned
to each type of want may be different from another,
based on the organization’s strategy. If the organization’s
strategy is to preserve the current situation, the focus is on
“Must-be” want. Therefore, the wants of this type are given
higher weights. On the other hand, if the strategy of the
organization is to attract new customers, the “attractive”
wants are given higher weight. For this purpose, according
to the opinions of hospital managers, the assigned weight
to “ Must-be,” “one-dimensional,” and “attractive” want are
5, 3, and 1, respectively. Table 4 shows that there are 2
“Attractive” clients’ wants, 15 “One-dimensional” clients’
wants and 13 “Must-be” clients’ wants.
Calculating the Weight of the Customers’ Wants
Table 4 shows the final weights of the customers’ wants in
which R26, R25 and R16 have the highest weights.
Calculating the Weight and Prioritization of the Corrective
Activities
In this step, the weights of the corrective activities are
Improving the Quality of Hospital Services Using the QFD Beheshtinia etal
7

Table 4. The Wants’ Importance Degree, Type, and Weight

Client Request Importance Degree Request Type Kano Weight Absolute Weight Relative Weight

R1 3.982 O 3 11.945 0.024

R2 4.252 M 5 21.26 0.044

R3 4.281 M 5 21.403 0.044

R4 4.174 M 5 20.87 0.043

R5 4.351 M 5 21.753 0.045

R6 4.501 O 3 13.504 0.028

R7 4.317 O 3 12.951 0.027

R8 4.153 O 3 12.46 0.026

R9 4.205 O 3 12.616 0.026

R10 4.475 M 5 22.377 0.046

R11 4.499 M 5 22.494 0.046

R12 4.41 O 3 13.231 0.027

R13 4.362 O 3 13.085 0.027

R14 4.566 O 3 13.699 0.028

R15 4.083 O 3 12.249 0.025

R16 4.514 M 5 22.571 0.046

R17 4.39 M 5 21.948 0.045

R18 4.353 O 3 13.06 0.027

R19 4.514 O 3 13.543 0.028

R20 4.34 M 5 21.701 0.044

R21 4.322 A 1 4.322 0.009

R22 4.47 O 3 13.41 0.027

R23 4.249 O 3 12.748 0.026

R24 4.605 O 3 13.816 0.028

R25 4.532 M 5 22.662 0.046

R26 4.54 M 5 22.701 0.046

R27 4.275 M 5 21.377 0.044

R28 4.309 O 3 12.927 0.026

R29 4.184 A 1 4.184 0.009

R30 4.306 M 5 21.532 0.044

calculated based on the equations (3) and (4). Table if the assigned budget is lower than sum of the corrective
5 shows the absolute weight, relative weight, and the activities costs some corrective activities will not be
corrective activities ranks that A12 and A3 have the highest selected. Table 6 shows the list of optimum corrective
weight and A11 and A6 have the lowest weight. activities under various assigned budgets.

Estimating the Cost of Implementing Each Corrective Discussion

Activity
In this step the cost of implementing each corrective
activity is estimated using the fourth questionnaire. The
results are shown in Table 5.
Employ KPMM to Select Optimum List of Corrective
Activities
In this step the optimum list of corrective activities is
obtained under various values of budget using KPMM.
If the assigned budget is equal to sum of the corrective
activities costs, all corrective activities are selected. But
Some advantages of the proposed approach are as
follows:
• Considering the type of need and its importance
degree in determining the weight of customers’ wants,
simultaneously to improve hospital services quality.
• Applying the organizations strategies in determining
the weight of customers’ wants and subsequently
in the weight of corrective activities as mentioned
previously.
• Selecting the optimum set of corrective activities
under budget constraint.

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 8 Beheshtinia etal Improving the Quality of Hospital Services Using the QFD

Table 5. Weight, Rank and Cost of the Corrective Activities If original QFD approach such as the exerted QFD
Corrective Absolute Relative Estimated Cost in24,25,32 is applied, the client wants of “Special attention to
Rank
Activity Weight Weight (US Dollar) specific patients”, “Enough manpower”, and “Professional
1 A12 2807.789 0.118 52000 and experienced doctors and nurses” obtain the highest
2 A3 1627.345 0.068 9000 weight because they have the highest importance degree.
But, in this research the client wants of “Professional and
3 A18 1446.789 0.061 69000
experienced doctors and nurses”, “Healthy and sufficient
4 A20 1360.043 0.057 169000
consumables”, and “Environmental cleanliness” obtained
5 A24 1307.612 0.055 1000 the highest weights among all wants. It is because
6 A2 1248.642 0.053 17000 the type of these client wants are “Must-be” and their

7 A19 1213.092 0.051 169000

importance degrees are multiplied by a high coefficient.
Although, Special attention to specific patients” and
8 A1 1163.356 0.049 17000
“Enough manpower” have the highest importance degree
9 A13 1141.904 0.048 169000
but their type is “One-dimensional” and their importance
10 A7 1067.338 0.045 9000 degrees are multiplied by a lower coefficient. The results
11 A29 923.9935 0.039 17000 of the exerted approach are flexible and by changing the
strategies of the organization, the Kano weights and the
12 A14 771.192 0.032 17000
clients’ wants’ weights will accordingly be changed.
13 A16 729.498 0.031 17000
Using the Kano analysis for obtaining the weights of
14 A21 688.6482 0.029 9000 the customers’ wants allowed for the organization’s
15 A9 686.627 0.029 52000 strategies to be considered in determining the priority of
16 A22 613.8711 0.026 169000 the corrective activities. According to the organization’s
strategy, the weight assigned to each type of wants may
17 A5 607.5665 0.026 85000
be different from another. On the other hand, using KPMM
18 A17 589.0441 0.025 34000
leads to selection of optimum set of corrective activities
19 A8 475.7866 0.02 33000 under budget constraint.
20 A4 475.1257 0.02 32000

21 A30 421.4588 0.018 1000

Conclusion
Like other service organizations, hospitals provide services
22 A27 404.2391 0/017 69000
to their customers and seek customer satisfaction. This
23 A10 325.7928 0/014 1000 research aimed to improve hospital services quality
24 A26 322.9543 0.014 17000 through QFD and its integration with the Kano analysis
25 A23 311.1328 0.013 1000 and KPMM. For this purpose, at first, the customer’s wants
were identified, and the corrective activities required to
26 A15 301.714 0.013 17000
satisfy them were obtained. Consequently, the relationship
27 A25 223.3374 0.009 17000
between each customer want and each corrective activity
28 A6 177.7658 0.007 9000 was determined. Then, each customer want’s importance
29 A28 170.1846 0.007 53000 degree and type were determined based on the Kano
30 A11 153.3022 0.006 17000 analysis. Subsequently, the weight of each clients’ wants

Table 6. List of Optimum Corrective Activities Under Various Budgets

Selected Corrective Activities Assigned Budget (US Dollar)

All activities 1348000

All activities except A22, A27 and A28 0.8×1348000=1078400

All activities except A5, A13, A22, A27 and A28 0.6×1348000=808800

All activities except A11, A13, A19, A20, A22, A27 and A28 0.4×1348000=539200

All activities except A4, A5, A8, A9, A11, A13, A15 A17 A19, A20 A22, A25, A27 and A28 0.2×1348000= 269600

No activity 0

Int J Hosp Res 2018, Volume 7, Issue 3

Improving the Quality of Hospital Services Using the QFD
and corrective activity was calculated. Finally, the cost of
implementing each corrective activity is estimated and
the set of optimum corrective activities under budget
constraint is determined using KPMM.
It is suggested that hospital managers consider the
proposed list of clients’ wants and corrective activities
to have better insight about their customers. The priority
and the weight of corrective activities are related to weight
of clients’ wants. Therefore, any change in the weight of
clients’ wants, change the priority of clients’ wants. It is
suggested to managers using the proposed approach
and deals their strategies by assigning scores to type of
clients’ wants. Moreover, it is suggested that managers
use KPMM to determine the optimum set of corrective
activities under budget constraint.
Using the proposed approach in other service
organizations such as banks, hotels and training
centers may be the scope for future research. Adding
other techniques such as MCDM techniques,
envelopment analysis 46-49
or supply chain aspects
the approach could be another scope for future studies.
Employing fuzzy methods in determining the weight of
the corrective activities may also be considered in future
research.
Abbreviations
(QFD): Quality function deployment; (HOQ): House of
quality; (MCDM): Multi-criteria decision making; Knapsack
Problem Mathematical Model (KPMM).
Competing Interests
The authors declare no competing interest.
Authors’ Contributions
MAB conceived of the presented idea. AM developed the
theory and performed the computations. MK wrote the
paper.
Acknowledgements
The authors would like to thank to the hospital managers
who made a sincere cooperation to conduction of this
study.
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